"Same structure, different function." Those four words are the reason SLPs treating a child's speech problem may also grapple with an overlapping feeding disorder. "There is often a correlation between speech and feeding," noted Melanie Potock, MA, CCC/SLP, who devotes 99% of her practice to in-home feeding therapy. "If a child is having trouble with speech due to low muscle tone, and/or difficulties with facial muscle movement that is required to talk, those problems are apt to impact their eating, too."
Additionally, Potock pointed out that children with autism spectrum disorder (ASD) may find their way to speech therapy due to sensory overload that hinders their ability to communicate effectively. That same sensory overload may also impact their ability to try new foods or be part of family dinnertime.
Many SLPs have only cursory introductions to feeding disorders in their education, and at this time there is no certification, per se, approved by American Speech-Language-Hearing Association (ASHA) for feeding specialists. However, those interested can gain this important expertise by taking ASHA-approved coursework and getting CEUs, working in hospitals or clinics with feeding programs, and working collaboratively with other SLPs, as well as OTs, PTs, and board-certified behavior analysts (BCBA) to be sure they can provide the best therapy for young patients who are eating-challenged.
Using a Trust Model
That "best therapy" for young patients comes down to "trust," according to Jenny McGlothlin, MS, CCC/SLP, who runs a feeding program at the University of Texas Dallas-Callier Center for Communication Disorders. It sounds like a very unscientific beginning to solving a child's eating problem, but McGlothlin explained the dynamics of the trust-based paradigm that has been so successful at her practice.
"Some programs use a behavioral modification approach - a theory that comes out of the psychology realm. But behaviors are usually the end result of many other things - a whole multitude of problems," she said. "Many of the children we see were once preemies - their sensory systems didn't have time to fully develop." Noting that the mouth has more sensory receptors per square inch than any other part of the body, it is not surprising then that children with immature neurological systems experience hyper reactions to newly introduced foods.
"The babies may have had a very negative reaction to feeding early in life because it just wasn't pleasant for them. They may have experienced reflux as well," said McGlothlin. "With all of these negative reactions the babies eventually just don't want to eat. If every time you eat it hurts, or aspirates into your lungs, you wouldn't want to eat either."
As those babies become toddlers, problems can persist. From an oral motor standpoint, the act of feeding is complex and requires a great deal of versatility of movement from mouth, jaws, tongue, facial muscles, etc. "If children don't have the strength and range of movement, the awareness of pressure, the ability to combine the sensory sensations and attempt a good motor response, they'll be lost," said McGlothlin. "A child might well feel the texture of a food, and like the taste, and know that it needs to be chewed. But he may not be able to get it over to his teeth to chew it, and he might give up, spit it out, try to swallow it hole, or gag. There are so many variables."
Very often, that is when high anxiety sets in for both parents and child. And that is exactly when the "trust" is so integral.
"Parents must learn that children's refusal to eat is a form of communication," said McGlothlin. "They are giving us a window into what is wrong with them. It's the job of caregivers and the parents to help determine what the problems are then support children in a developmentally appropriate way by reading their cues and not pushing them too fast. We have to teach parents to trust that their child will let them know what foods they are ready for, and the child must be able to trust that the parents will provide support and not push them too fast beyond their capabilities. Feeding is relational."
McGlothlin takes issue with those therapists who advise feeding the problem eater outside the family meal, one-on-one. She believes mealtime is the perfect time to build the trust that is needed. She also decries the idea of offering external reinforcement to coax a child to eat.
"A more behavioral model of therapy might allow a child to play with a toy in exchange for taking a bite of food, or allow a video to be played I exchange for eating," she explained. "But that theory backfires - the child disassociates and does not learn to eat as a response to internal cues - like hunger - or how to eat with good oral motor skills, because a child cannot pay attention to his mouth when he is watching television. It is not developmentally appropriate. That child is being set up for longer-term issues."
Stacking Up Care
Potock also embraces a "whole child" approach to practice, in fact it is the first in a three-step "stacking" method that she has devised and uses when teaching feeding seminars to SLPs across the country. Here's how they stack up:
First stack: Pay attention to the whole child, his entire physiology. "Collaborate with other care providers, to determine if anything is going on -- in the stomach, the GI tract, with constipation, food allergies, etc. - to impact a child's willingness to eat. A child with arthritis, for example, or one with a painful club foot is more likely to pay attention to that pain and discomfort than to hunger," Potock said. She also said it is vital, at this first stage, to assess sensory processing, which is also a function of physiology.
Second stack: Assess motor skills. "This is where the therapist must approach the feeding problem from a developmental perspective. If a child isn't crawling at 12 months, the therapist must consider whether the child's gross motor skills and stability allow for the development of the fine motor skills required for eating," said Potock. She said collaborating with PTs and OTs can be extremely helpful in this phase.
Third stack: Look at behaviors. The therapist's quest must be to discover why a child learned, at a very young age, to turn away from food. "We need to understand what the child is trying to protect himself from - what discomfort brought him to these behaviors," said Potock. She noted that it is important to understand the behaviors a child uses to avoid or pursue particular foods. It is just as important to observe a family's behavior that may or may not influence how a child eats. "Sometimes a parent reinforces a behavior unwittingly, and we can help them make important changes at mealtimes. We can help them de-stress, and that automatically helps a child de-stress as well," she said.
Asked if there were one piece of advice she would offer to SLPs hoping to get more involved in feeding therapy, Potock said it is best to embrace a trans-disciplinary model of care and learn the best from a provider on your team. "Sure, we can work on mechanics, fine and gross motor skills, etc., but we also need to learn and understand about applied behavioral analysis which is growing in the expanding face of autism diagnoses. Feeding therapists need to welcome and collaborate with board-certified behavior analysts, although some SLPs and OTs resist. It is important to remember we each have our role. And if we don't understand behavior 24/7 around a family and around a child, we aren't going to be able to make significant changes during family mealtime. And let's face it, learning to eat is not just about chewing a hunk of broccoli. It's eventually about having joyful family mealtimes."
The fast track to that joy, in McGlothlin's view, comes through empowering both parent and child with mutual trust, and imbuing a parent with understanding of what normal oral motor development and feeding looks like, and a skill set to thoughtfully tackle the issues their children are experiencing.
"When parents learn to make adjustments - to change a presentation on a plate, or to decrease their anxiety level when a child spits out a food they just can't handle, then mealtime can stop being a battleground," she said. "When we give a child trust and some autonomy, they tend to push themselves along. When parents feel competent at offering their children support, structure and healthful food choices appropriate to their children's level of ability, they also feel like more competent parents. And that feels good."
Valerie Neff Newitt is on staff at ADVANCE. Contact: firstname.lastname@example.org.